EVALUATION OF PRESCRIBING PATTERN IN ORTHOPEDICS DEPARTMENT IN A TERTIARY CARE HOSPITAL: A PROSPECTIVE OBSERVATIONAL STUDY

Objective: To study the demographic profile and prescription pattern in Orthopedics department in a tertiary care hospital. Methods: A prospective, observational and cross-sectional study design was adopted for this study. A total of 144 patients were enrolled and their prescriptions were analyzed for three months. The data was analyzed by using a Microsoft Excel Worksheet. The Anatomical Therapeutic Chemical classification system and defined daily dose were used to classify the prescribed drugs. Results: Out of 144 patients enrolled, 105 (72.92%) were male and 39 (27.08%) were female. Maximum patients were between 21-40 y of age. The mean age of the patients was 35.04±18.53. The average number of drugs per prescription was 4.84. Fracture of limbs (58.33%) was the most common diagnosis. Analgesics were the most commonly prescribed drugs. Diabetes was the most common comorbidity. The percentage of drugs prescribed by generic names was 48.06, and that from the essential drug list was 47.78. The percentage of fixed-dose combinations used was 28.55. Conclusion: Although we found that a good percentage of drugs were prescribed from essential drug list but, this practice has to be increased in future. It is also seen that average number of drugs per prescription was high and percentage of drugs prescribed by generic names was less than that by brand names. So, there is immense scope of improvement for prescribing in the hospital.


INTRODUCTION
Prescription writing is an art.It is the direction the prescriber gives to both pharmacist and patient for the proper use of drugs [1].Thus, a prescription reflects the physician's perspective towards the particular disease and the role of the medication in its treatment.It also provides an understanding of the essence of the healthcare delivery system [2].
Monitoring of prescriptions and drug utilization studies help in examining the recent trend of prescription patterns which helps in identifying the problems and providing feedback to prescribers.Thereby, awareness can be created about the irrational use of drugs.It is an inevitable need to investigate thoroughly the factors affecting the prescribing patterns of the doctor to improve the prescription quality and promote rational prescription patterns [3].
World Health Organization (WHO) definition of rational prescription is ''Rational use of medicines requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements, for an adequate period of time, and at lowest cost to them and their community.''[4].
WHO developed a set of core drug-use indicators that include the average number of medications per prescription, percentage of antibiotics, percentage of generics and brands, percentage of injections and percentage of drugs prescribed from an essential medicine list [5].
Drug utilization studies are mainly of two types: quantitative and qualitative [6].WHO defined drug utilisation as the marketing, distribution, prescribing, dispensing and administration of medication, with consideration of its use economic burden [5].International agencies such as the WHO and International Network of Rational Utilization of Drugs have deciphered the importance of drug utilization studies in the promotion of rational drug use and their application have helped them to evolve standard drug use indicators and data collection methods [7].
Defined Daily Dose (DDD) is an important tool to compare drug utilization among different clinical setups within a country and between different countries.DDD/100 bed-days provides a rough estimate of drug consumption in hospital inpatients and it is a fixed unit of measurement independent of formulation and price [8,9].
Physicians in their day-to-day practice, prescribe a greater number of fixed-dose combinations (FDCs) [10].Unfortunately, most of them are irrational and harmful.It is crucial that principles of rational prescription are adhered to and an important step toward this is by prescribing drugs only published in the WHO Essential Medicines List (EML) or National List of Essential Medicines (NLEM).
The prescribing pattern of drugs in the orthopedics field has to be regularly observed as many of the drugs prescribed have unwanted adverse effects.The objective of conducting a prescribing pattern study is to monitor, evaluate, and if necessary, suggest modifications in the prescribing behavior of medical practitioners to make medical care cost-effective and rational [11].
This study was undertaken as an attempt to know the disease pattern and also prescribing practices in the orthopedics in-patient department of the tertiary care hospital of Guwahati, Assam.Moreover, this study was also performed to evaluate whether the prescribed drugs were enlisted under the WHO Model List of Essential Medicines 2021 (22 nd list) and prescribed by generic name.

MATERIALS AND METHODS
A prospective, observational and cross-sectional study design was adopted for this study.The data was collected from October to December 2022 at Orthopedics in-patient department of a tertiary care teaching hospital in Guwahati, Assam.Patients of all age groups, both male and female patients from the Orthopedics in-patient department with other comorbidities were included in the study.The patients were enrolled only after their prior consent.Patients from the outpatient department, those admitted to other in-patient department, patients who absconded or discharged against medical advice and pregnant women were excluded from the study.The Institutional Ethics Committee permission was taken to conduct this study (IEC approval no.MC/190/2007/Pt-II/JUN-2022/17).
The sample size of this study was 144 and the data from the prescription of the patient was noted in profile forms and entered in a Microsoft Excel Worksheet and descriptive statistics such as mean, frequency and percentage were calculated.
The Anatomical Therapeutic Chemical (ATC) classification system and defined daily dose (DDD) were used to classify the prescribed drugs.The ATC system divides the active substances into groups and subgroups, and the DDD is the assumed average maintenance dose per day for a drug when used for its main indication in adults.The DDD provides a fixed unit of measurement, independent from, e. g., strength and price, which enables research on patterns in the prescription of drugs [12].

RESULTS
In the present study, 144 patients were enrolled and their prescriptions were analyzed during 3 mo.We observed that there were 697 drugs prescribed and the average number of drugs per prescription was 4.84.Out of 144 patients enrolled, 105 (72.92%) were male and 39 (27.08%) were female (fig.1).Demographic details revealed that the patients of age between 21-40 y were more (56 patients) followed by 41-60 y (41 patients), then 0-20 y (36 patients) and 61-80 y (11 patients) (table 1).This described the effect of age factor on disease distribution.The mean age of the patients was 35.04±18.53.The majority of the patients who were admitted in-patient ward of the Orthopedics Department had suffered from a fracture of limbs i.e. 84(58.33%),followed by 38(26.39%)patients with other orthopedic ailments,15(10.42%)patients with soft tissue injury, 4(2.78%) patients with osteomyelitis and 3(2.08%) patients with congenital anomalies (fig.2).Analgesics were the most commonly prescribed drugs in the Orthopedics Department.There were 190 analgesics (27.26%), followed by 169 antibiotics (24.25%), 119 gastroprotective drugs (17.07%), 80 miscellaneous drugs (11.48%), 57 Calcium and Vitamin D (8.18%), 51vitamins (7.32%) and 31 antiemetics (4.45) (fig.3).In table 3, ATC classification of 169 antibiotics along with their individual WHO-assigned DDD (in mg), routes of administration and number of individual antibiotics have been mentioned.In table 5, ATC classification of 80 miscellaneous drugs along with their individual WHO-assigned DDD-Defined Daily Dose (in mg), routes of administration and number of individual miscellaneous drugs have been mentioned.In table 8, ATC classification of 31 antiemetics along with their individual WHO-assigned DDD-Defined Daily Dose (in mg), routes of administration and number of individual antiemetic drugs have been mentioned.The rationality of a prescription can be evaluated by the total number of drugs prescribed for a patient.The more the number of drugs prescribed, the more the development of resistance, adverse drug reactions and other drug-related problems.Indirectly it may affect the patient's adherence towards treatment.However, according to the severity of the disease, multiple drugs are prescribed for the treatment [13].In the present study, 45 patients (31.25%) were prescribed with 3-4number of drugs, followed by 31 patients (21.53%) with 1-2 drugs,30 patients (20.83%) with 5-6 drugs, 23 patients (15.97%) with 7-8 drugs and 15 patients (10.41%) with equal or more than 9 drugs (fig.4).
Rationality of prescriptions was assessed using WHO core prescribing indicators, values of which are presented in table 10.In this study out of 697 prescribed drugs, 391 drugs were given orally and 306 drugs were given parenterally as shown in fig. 5.

Fig. 5: Routes of administration
In this study, out of 697 prescribed drugs, 335 drugs were prescribed by their generic names and 362 drugs were prescribed by their brand names as shown in fig.6.
The following table shows the number of fixed-dose combinations used in each category of drugs, along with their percentages (table 11).In our study, a total of 199 (28.55%)FDCs were used.

DISCUSSION
This study was carried out to know the prescribing pattern of drugs used in the Orthopedics In-patient Department of Gauhati Medical College and Hospital, Guwahati.During the period of study, sex-wise distribution of patients shows that male patients (105 out of 144) were found to be more than that of female patients (39).Male dominance was also found in Gupta et al. [14] study, where 315 male and 185 female patients were enrolled based on only non-steroidal anti-inflammatory drugs (NSAIDs) use.Again in our study, the number of patients was higher in the age group of 21-40 y i.e. 56, which is similar to Ingle et al. [15] study where the number of patients was also more i.e. 91 in the age group of 18-40 y.When we compared the average number of drugs (4.84) prescribed in our study was found to be more than several other studies i.e. 3.5 in Alshakka et al. [16], 1.33 in Das et al. [17] and 1.9 in Shankar et al. [18] study, at par (4.72) with Mishra R et al. [19] and less than (8.86) that of Baghel R et al. [20] study.
Analogous to our study, Choudhury et al. [21] study had also reported fracture as the most common diagnosis encountered in Orthopedics In-patient.NSAIDs were the most commonly prescribed drugs in our study, similar to Shehnaz et al. [22] study.Among the NSAIDs, paracetamol was the most prescribed NSAID, similar to that of Patil LV et al. [23] study.In the present study, we observed that gastroprotective agents Proton-pump inhibitors (PPIs) were coadministered with NSAIDs.The most commonly prescribed PPI was pantoprazole (84.03%) (table 4).The main reason for their use was NSAID-associated peptic ulcer and gastrointestinal bleeding [24].In Rahman MS et al. study revealed that the proton pump inhibitors were used as the anti-ulcer agents of choice [25].
In our study, out of 144 patients, 26 of them also had other comorbidities and it was seen that Diabetes was the most common comorbidity just as Narne et al. [13] study.Again, when we compared the number of drugs per prescription given to patients, it was seen that in our study, a maximum of 45 patients were prescribed 3-4 drugs in contrast to Narne et al. [13] study, where 69 patients had 4-6 drugs.
The use of Fixed Dose Combinations (28.55%) was found to be much higher than that reported in the Shankar PR et al. (13.1%) study [18] but lower than that reported by Das et al. (36.25%) study [17].Moreover, the use of parenteral preparations (43.90%) was found to be much higher than that reported in the Shankar PR et al. (8.6%) study [18] and Das et al. (17.4 %) study [17].
Most of the drug utilization studies have reported that the majority of the drugs were prescribed by brand names.Shankar PR et al. [18] study and Shankar PR et al. [26] study found 80.7% and 67.4% prescriptions in brand names, respectively, similar to our study (51.94%).Analogous to our study (48.06%), in Alam K et al. study (44%) too drugs were prescribed by generic names [27].Generic drugs are usually inexpensive than brand drugs [22].The percentage of drugs prescribed from the WHO essential drug list was 47.78% in contrast to Ingle et al. (51.05%) study [15].

LIMITATIONS
The limitations of our study were that the period of our study should have been longer so that we could have included more number of patients and analyzed their prescriptions to get better results and observations.We should have also included OPD patients to get the statistics about the average consultation and dispensing time of the drugs.

CONCLUSION
The study shows that a good percentage of drugs were prescribed from the essential drug list, but this practice has to be increased in future.Again, the average number of drugs per prescription was high, so the physicians must make the habit of reducing the number of drugs per prescription to avoid adverse drug reactions.Although a good number of drugs were prescribed by their generic names, it was less in comparison to that of brand drugs.Regular educational interventions at different levels further promote rational prescribing.

Fig. 4 :
Fig. 4: Number of drugs per prescription with number of patients

table 2 :
ATC classification of 190 analgesics along with their individual WHO-assigned DDD (in mg), routes of administration and number of individual analgesics have been mentioned.

Table 3 : Antibiotics with ATC code, DDD (mg) and route of administration
In table 4: ATC classification of 119 gastroprotective drugs along with their individual WHO-assigned DDD-Defined Daily Dose (in mg), routes of administration and number of individual gastroprotective drugs have been mentioned.

Table 5 : Miscellaneous drugs with ATC code, DDD (mg) and route of administration
In table 6: ATC classification of 57 Vitamin D and Calcium drugs along with their individual WHO assigned DDD-Defined Daily Dose (in mg), routes of administration and number of individual Vitamin D and Calcium drugs have been mentioned.